Preparing for Induction
After determining that a patient is appropriate for buprenorphine treatment, the clinician should do the following before starting induction:
- Conduct a history & physical
- Verify the patient's list of medications, illicit drugs, and alcohol use
- Conduct a brief psychosocial assessment
- Conduct lab testing: liver function tests, urine toxicology screen, pregnancy test
- Have patient review and sign consent forms and treatment agreement
- Determine when and where to start induction (clinic vs. home induction)
- Provide education to the patient about the induction, stabilization, and maintenance processes
- Advise patients not to use opioids for appropropriate amount of time to prevent precipitated withdrawal
- Recommend that the patient get a friend or family member to drive them home if doing clinic-based induction
Preparing for the First Dose
When presenting for their first dose, patients should be in mild to moderate withdrawal. Patients who are dependent on short-acting opioids should abstain from 12 to 24 hours before beginning induction to achieve this; it will take 36 to 72 hours for those dependent on methadone.
It is important to use an objective measure - like the Clinical Opioid Withdrawal Scale (COWS) - to evaluate the patient's withdrawal symptoms prior to induction since patients may exaggerate their symptoms to avoid discomfort. When patients have a COWS score about 12 or 13 (mild to moderate withdrawal), they are ready for their first dose.
The biggest concern in transferring patients from methadone to buprenorphine is precipitated withdrawal. In order to minimize this risk, patients who are maintained on high doses of methadone should be tapered down to a 30 mg daily dose (ideally) just prior to transfer and maintained on this dose for a week.